complaint·April 23, 2024

The investigation revealed the following: Regarding the allegation " questionable deaths ”, it is alleged that Resident 1 (R1) - Resident 6 (R6) did not seem to be ill and upon developing a medical diagnose they passed away within days. Complainant is not aware if any of the residents had any underlining conditions. Staff interviewed stated these residents had underlying conditions and were placed on hospice, and that their death were not due to neglect. Review of records all residents were on hospice. LPA obtained copies of death certificates for all residents. R1 (80 years old) passed away on 06/12/2022: immediate cause of death was cardiopulmonary arrest, and the underlying causes were acute respiratory failure and Covid-19. R2 (86 years old) passed away on 06/06/2022: immediate cause of death was Alzheimer’s Disease. During the investigation, LPA could not determine the true name of R3. Staff stated there has been no resident with that name or a resident that matches the details provided by the complainant. R4 (84 years old) passed away on 12/05/2021: immediate cause of death was cardiopulmonary arrest, and the underlying cause was senile dementia. R5 (82 years old) passed away on 03/17/2022: immediate cause of death was cardiopulmonary arrest, and the underlying cause were urosepsis and atherosclerosis of coronary artery. R6 (83 years old) passed away on 12/18/2021: immediate cause of death was cardiac arrest, and the underlying cause were respiratory failure and Parkinson’s disease. Residents interviewed did not express that they are being neglected. Regarding the allegation " residents had severe UTI ”, it is alleged that R4, R5 and R6 had UTI. Staff interviewed stated that residents do get UTI, but it is not due to neglect. They stated all residents that need diaper change receive incontinence assistance every 2 hours or as needed and staff are trained to properly cleaned the residents to avoid UTI. Residents interviewed did not express that they are being neglected. Regarding the allegation " staff did not seek medical attention for residents ” , it is alleged tha t R3's tube (unsure type of tube) that was attached to R3's stomach looked infected. Complainant did not provide a last name for R3. During the investigation, LPA could not determine the true name of R3. Staff stated there has been no resident with that name or a resident that matches the details provided by the complainant. Residents interviewed could not corroborate the allegation. (Continued to LIC 9099-C) Regarding the allegation "staff did not follow prescribed meals for residents”, it is alleged that R3 was on mechanical soft food diet, but staff kept feeding R3 regular food. Complainant did not provide a last name for R3. During the investigation, LPA could not determine the true name of R3. Staff stated there has been no resident with that name or a resident that matches the details provided by the complainant. Staff interviewed denied the allegation stated that they follow a list that is on the kitchen that has all the residents with modified/prescribed diets. Residents interviewed could not corroborate the allegation. LPA observed the list for modified/prescribed diets in the kitchen. Regarding the allegation "staff did not report incidents to CCL” and "staff did not document residents falls", it is alleged that a resident had a fall and it was not documented or reported to Community Care Licensing (CCL). There is no records of this resident having a fall and staff could not remember if this resident had a fall either. Staff stated that the procedure regarding falls is as follows: contact the med-techs to come and assess the resident, write a report and submit it to supervisor. S1 is in charge of completing the licensing incident report and submitting it to the Executive Director for signature and the Executive Director submits it to CCL. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was provided